医疗改革

　　Looking to Uncle Sam

　　瞧瞧山姆大叔

　　As lawmakers squabble, spending on health care continues to grow

　　由于立法议员争执不下，医疗保健支出继续增加

　　Jul 30th 2011 | NEW YORK | from the print edition

　　POLITICIANS want to lower spending, or at least they say they do. But in all the to-and-fro over raising the debt ceiling, little sensible has been said about lowering spending in the long term. Nothing illuminates this more clearly than health care.

　　政客们想要减少支出，或者至少他们嘴上是这么说的。然而在总体上，债务限额一次又一次的争论增加了债务限额，而没有意识到减少支出这一长期要求。没有比医疗保健更能清楚地解释这。

　　A new report, published in Health Affairs on July 28th, paints a daunting picture. Health spending will rise by 5.8% each year from 2010 to the end of 2020, according to actuaries at the Centres for Medicare and Medicaid Services (CMS). In 2020 health care will account for one-fifth of America’s economy. The federal government will pay for a greater share than ever before.

　　发表在7月28日《卫生事务》上的一个最新报告，描绘了一个令人望而生畏的画面。根据医疗保险和医疗补助服务（CMS）中心的精算师的预测，从2010年到2020年，医疗支出每年都将增加5.8%。到2020年，医疗保健将会占到美国经济的五分之一。联邦政府将会支付比以往更多的份额。

　　Hawks have long warned that it would be impossible to curb government spending without curtailing spending on health. Democrats claimed that their health law would lower costs. Barack Obama assembled grey-haired sages to recommend changes to entitlement programmes. Paul Ryan, the Republican chairman of the House Budget Committee, offered his own reforms. And yet spending on health care continues to climb.

　　赤字鹰派早已警告说，不缩减医疗支出而抑制住政府支出将是不可能的。民主党声称他们的卫生法会减少花费。奥巴马综合了灰白头发的专家们的意见，建议改变福利计划。众议院预算委员会主席共和党人保罗?瑞安提出了他自己的改革。可是医疗保健支出继续攀升。

　　Last year the actuaries at CMS projected that health reform would not lower spending, as Democrats hoped. From 2009 to 2019 average annual growth for health spending would be 0.2 percentage points higher with Mr Obama’s health reform than without it. This slight net rise would mask dramatic shifts, the actuaries said. For example, reform’s efforts to contain costs for Medicare, the government programme for the old, would be dwarfed by the expansion of Medicaid, the government programme for the poor.

　　正如民主党希望的那样，去年CMS的精算师预计医疗改革支出不会减少。和没有奥巴马的医疗改革相比，从2009年到2019年医疗支出平均每年增加高出0.2个百分点。精算师说，这种轻微的净增加掩饰了戏剧性的转变。例如，政府针对穷人的医疗补助费用大幅增加,使得政府为控制老年人医疗保险成本所作的努力大打折扣。

　　The actuaries’ newest study estimates that health spending grew little last year, mostly because of the weak economy. The next decade, however, will bring rapid growth. Government spending will be the main driver. Ageing baby-boomers will enroll in Medicare; Medicaid coverage will swell; Washington will subsidise many of those on the new state exchanges. CMS expects Washington’s share of health spending to grow from 27% in 2009 to 31% by 2020. Together with spending by states and cities, the public sector will pay for nearly half of America’s health care.

　　精算师最新的研究估计，去年医疗支出没怎么增加主要是因为经济的疲软。然而，接下来的十年，医疗支出会迅速增加。政府支出将会是主要的驱动力量。婴儿潮时出生的人正在变老，并将加入到医疗保险的行列；医疗补助覆盖范围将会扩大；华盛顿将会资助许多新建的州医疗保险交易所。CMS预计华盛顿医疗支出份额将会从2009年的27%增加到2020年时的31%。和州以及市的支出一起，公共部门支出几乎达到美国医疗保健的一半。

　　This is a sobering prediction. However, even this may be an underestimate. The actuaries at CMS assume that only 2m people who now have employer-sponsored insurance will lose it, as companies drop coverage and workers move to exchanges or to Medicaid. But more may make the switch. In June McKinsey, a consultancy, found in a survey that 30% of firms would definitely or probably stop offering insurance after 2014, when the exchanges are in place. On July 25th the National Federation of Independent Business, which represents small firms, published its own survey. If some workers begin to move to exchanges, the report found, 57% of companies would consider dropping insurance completely. If these surveys are borne out in firms’ actions, government spending will be even higher than CMS expects. The debt disaster on August 2nd may be averted. The bigger problem remains.

　　这是一个触目惊心的预测。然而，即使是这样，也许是低估。由于企业降低覆盖面以及工人转向医疗保险交易所或医疗补助，CMS的精算师假设只有200万人将会失去了雇主提供的保险。然而也许更多人遭遇了此种情况。6月份咨询公司麦肯锡调查发现2014年后，医疗保险交易所到位后，30%的公司肯定或也许会停止提供保险。7月25日代表小公司的美国独立企业联合会发表了它自己的调查报告。报告指出，如果一些工人开始转向医疗保险交易所，57%的公司会考虑完全取消保险。如果这些调查刺激了公司的实际行动，政府支出甚至将会超过CMS的预期。8月2日的债务危机也许会避免。但是更大的问题仍然存在。